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Hypertension and nephrology

NOVEMBER 04, 2020

[The ACE2-Ang(1-7)-Mas axis as a new option for lowering blood pressure]

KÉKES Ede

[The ACE2-Ang(1-7)-Mas axis counterbalances the ACE/Ang II-AT1R axis in our body in order to maintain normal homeostasis. During the Covid-19 pandemic, this protective system came to the fore again and its beneficial effects on the cardiovascular-metabolic system, including the significant antihypertensive effect, are being clarified. In our brief summary, we analyze the essential aspects of this research.]

Lege Artis Medicinae

APRIL 18, 2020

[Interrelations between antidepressants and diabetes]

HARGITTAY Csenge, GONDA Xénia, MÁRKUS Bernadett, VÖRÖS Krisztián, TABÁK Gy. Ádám, KALABAY László, RIHMER Zoltán, TORZSA Péter

[Diabetes and depression are frequent comorbidities. They are a heavy burden by themselves, however, as comorbidities increase additionally the number of diabetes-related complications, morbidity, and mortality. In the background of interrelations, there are both well-known and hypothetical mechanisms. The aim of the present review is to outline these interrelations between antidepressants and diabetes and to discuss the effect of medications on carbohydrate metabolism respectively. Anti­depressant treatment on the one hand may improve mood, cognitive function and medication adherence leading to an improved glucose metabolism, on the other hand through their metabolic side effects, they may worsen carbohydrate metabolism. Concerning metabolic side effects, selec­tive serotonin reuptake inhibitors are the sa­fest, while tricyclic antidepressants and mo­noamine oxidase inhibitors should be administered under close monitoring. Se­rotonin and noradrenaline reuptake inhibitors may deteriorate gly­cae­mic control via increased noradre­nergic activation. Novel antidepressants, how­ever, have a neutral or positive impact on gly­caemic measures. Screening for and temporally adjusted treatment of depres­sion may decrease the risk of comorbidities ge­nerated complications. While caring for diabetic patients with depression, one should consider metabolic side effects of antidepressants and close monitoring of carbohydrate metabolism.]

Clinical Neuroscience

JANUARY 30, 2016

Unanswered questions in the transcranial magnetic stimulation treatment of patients with depression

MORVAI Szabolcs, NAGY Attila, KOVÁCS Attila, MÓRÉ Csaba, BERECZ Roland, FRECSKA Ede

According to the WHO fact sheet depression is a common mental disorder affecting 350 million people of all ages worldwide. Transcranial Magnetic Stimulation (TMS) is a technique which allows the investigator to stimulate and study cortical functions in healthy subjects and patients suffering from various mental and neurological disorders. In the early 1990s, studies revealed that it is possible to evoke long term mood changes in healthy volunteers by rapid rate repetitive, TMS (rTMS) over the frontal cortex. Subsequent studies involving depressed patients found frontal cortical rTMS administered daily to be clinically effective. In the past two decades, numerous trials examined the therapeutic potential of rTMS application in the treatment of mood disorders with constantly evolving treatment protocols. The aim of this paper is to review the literature of the past two decades, focusing on trials addressing the efficacy and safety of rTMS in depressed patients. Our primary goal is to evaluate the results in order to direct future studies which may help investigators in the development of treatment protocols suitable in hospital settings. The time is not far when TMS devices will be used routinely by practitioners primarily for therapeutic purpose rather than clinical research. To our knowledge, a widely accepted “gold standard" that would offer the highest efficacy, with the best tolerability has not been established yet. In order to approach this goal, the most important factors to be addressed by further studies are: localization, frequency, intensity, concurrent medication, maintenance treatments, number of pulses, trains, unilateral, or bilateral mode of application.

Clinical Neuroscience

MARCH 30, 2016

[The therapeutic use of transcranial magnetic stimulation in major depression]

NÉMETH Viola Luca, CSIFCSÁK Gábor, KINCSES Zsigmond Tamás, JANKA Zoltán, MUST Anita

[The antidepressive effect of repetitive transcranial magnetic stimulation (rTMS) has been investigated for almost 20 years now. Several studies have been published aiming to identify the exact and reliable parameters leading to the desired therapeutic effect. However, the related literature shows great variability. The current overview aims to provide a comprehensive overview of factors associated with the therapeutic effect of rTMS in major depression. High frequency stimulation of the left dorsolateral prefrontal cortex (DLPFC) for 3-6 weeks leads to mood improvement comparable to the effect of antidepressive medications in 35-40% of patients. Pharmacotherapy resistant patients treated with rTMS reach remission for 3 months on average. Low frequency stimulation of the right DLPFC appears to be similarly effective, though much less investigated so far. In addition to the exact delineation of the stimulation area, treatment outcome is also related to stimulation intensity as well as the number of sessions and impulses. Considering the safety and tolerability aspects of rTMS, it might be a significant therapeutic support for therapy resistant patients. Above this, patients diagnosed with major depression might benefit from the additional positive influence of rTMS improving the effect of antidepressive medication. Based on converging research evidence, the Food and Drug Administration (FDA) agency approved the use of rTMS as a treatment option for therapy resistant major depression in 2008. So far, in Hungary rTMS is primarily considered as a promising tool in research settings only. Hopefully, patients suffering from major depression will increasingly benefit from the positive therapeutic effect of this intervention.]

Clinical Neuroscience

NOVEMBER 20, 2015

[The diagnostic and management challenges for posterior reversible leucoencephalopathy syndrome]

KILIC COBAN Eda, GEZ Sedat, KARA Batuhan, SOYSAL Aysun

[Posterior reversible encephalopathy syndrome (PRES) is a clinicoradiological entity characterized by epileptic seizures, headaches, altered mental status and focal neurological signs. Hypertension is the second most common condition associated with PRES. The 50-year-old-male patient with right-sided hemiparesis and speech disturbances admitted to our clinic. His blood pressure at the emergency service was 220/140 mmHg. A left putaminal hematoma was seen in his CT and MRI. In his brain MRI, FLAIR and T2 –weighted sequences showed bilateral symmetric diffuse hyperintensities in the brain stem, basal ganglia, and occipital, parietal, frontal, and temporal lobes. After the intense antihypertensive drug treatment, his blood pressure came to normal limits within a week. During his hospitalisation he had a recurrent speech disturbance lasting an hour. His electroencephalography was normal. In his repeated diffusion weighted MRI, an acute lacunary infarct was seen on right centrum semiovale. Two months later, the control MRI showed only the previous lacuner infarcts and the chronic putaminal hematoma. We presented a case developping either a cerebral hemorrhage or a lacunar infarction due to PRES. The main reason of the following complications of the disease was delayed diagnosis. Uncontrolled hypertension was guilted for the events. ]

Lege Artis Medicinae

MARCH 10, 2020

[Recommendations of the European Atherosclerosis Society (EAS) and the European Society of Cardiology (ESC) for dyslipidaemia. Focused on: primary prevention]

BAJNOK László

[In 2019 the European Atherosclerosis So­ciety (EAS) and European Society of Car­dio­logy (ESC) renewed their dyslipidae­mia guidelines. The new version is more progressive than the previous ones. Thus, in the low-risk, not severely hy­per­choles­te­ro­lae­mic population cholesterol-lowering medication is also suggested. Except this low-risk group, atherogenic target values, e.g. for LDL-cholesterol, were reduced by an entire category, in some cases to the lowest one. If these goals cannot be achieved with statin-monotherapy, combined treatment is recommended generally by the cholesterol inhibitor ezetimib, and in some very high-risk cases also by innovative cholesterol lowering so-called PCSK9 inhibitor. ]

Lege Artis Medicinae

MARCH 10, 2020

[Primary care strategy of antihypertensive treatment of very elderly and frail patients]

TORZSA Péter, KALABAY László, CSATLÓS Dalma, HARGITTAY Csenge, MÁRKUS Bernadett, MOHOS András, SZIGETI Mátyás, FERENCI Tamás, MARJOLEIN Verschoor, ROZSNYAI Zsofia, JACOBIJN Gussekloo, ROSALINDE K. E. Poortvliet, SVEN Streit

[BACKGROUND - When treating very el­der­ly and frail hypertensive patients, there have to be taken in account the general health condition and frailty of patients, the present cardiovascular diseases (CVD) and values of the systolic blood pressure (SBP). Goals - In a clinical study performed in 29 countries, we aimed to analyse differences in practical antihypertensive therapy of family doctors among patients older than 80 years; further we sought to answer how much was influenced their therapeutic choice by frailty of the old age. The other goal of our study was to compare Hungarian versus international outcomes. Methodology - As part of an online survey, family practitioners had to decide about necessity of starting antihypertensive treatment among very elderly patients according to different patterns of frailty, SBP and CVD. The ratio of specific cases with positive treatment decision of family practitioners was compared in all 29 countries. We used a logistic mixed model analysis to multivariately model the role of frailty. Results - 2543 family practitioners participated in the cross-national study; 52% were female; 51% practised in urban environment. In 61% of practices, there was the ratio higher than 10% of very elderly patients. Hungary participated with 247 family practitioners in the study; 52.3% were female; 63.1% practised in urban environment. In 48.8% of practices the ratio of very elderly patients was higher than 10%. In 24 out of the 29 countries (83%), frailty was associated with GPs’ negative decision about starting treatment even after adjustment for SBP, CVD, and GP characteristics (odds ratio [OR 0.53]), 95% CI: 0.48-0.59; ORs per country 0.11-1.78). The lowest treatment ratio was in the Netherlands (34.2%; 95% CI: 32.0-36.5%) and the highest one in Ukraine (88.3%; 95% CI: 85.3-90.9%). In Hungary’s treatment ratio ranged 50-59%. This country ranked on the 27th place since Hungarian family practitioners chose rather to start antihypertensive treatment despite the frailty of the patient (OR=1.16; 95% CI: 0.85-1.59). Hungarian family practitioners started pharmacotherapy of elderly patients more frequently if they were males (OR= 1.45; 95% CI: 0.81-2.61), were working in their practice for less than 5 years (OR=2.41; 94% CI: 0.51-11.38), and if they had many patients aged over 80 years in their practice (OR=2.18; 95% CI: 0.70-6.80), however these differences were sta­­tistically not significant. Among Hun­ga­rian family practitioners starting therapy was significantly influen­ced by cardiovascular disease (OR=3.71; 95% CI: 2.64-5.23) and a SBP over 160 mmHg (OR=190.39; 95% CI: 106.83-339.28). Conclusions - In our study, there was significant difference between countries in starting antihypertensive treatment for very elderly patients. However, Hungary was among the countries where family practitioners preferred to treat their frail patients. The patients’ frailty did not have any impact on starting the therapy; rather cardiovascular disease and a SBP over 160 mmHg decided. It is an important message of the study that there is continuous need to educate family practitioners and trainees about the treatment of frail, elderly hypertensive patients.]

Lege Artis Medicinae

MARCH 10, 2020

[Diagnosis and treatment of the overactive bladder]

MAJOROS Attila, ROMICS Miklós

[The Overactive Bladder Syndrome (OAB) is a symptomatic diagnosis featured mainly by urgency of urine discharging. This condition can be triggered by a number of etiological factors, most of which are idiopathic in origin. Regardless of gender and age, the prevalence is ca. 16% and has a serious impact on the quality of life of the patients. In­ves­tigations are mostly performed through usual baseline examinations; second-line invasive examinations are rarely required. The broad spectrum of treatment options ran­ges from lifestyle changes and elimina­tion of triggering factors, through be­ha­vio­ural therapy and medication to the mi­ni­mally invasive (botulinum toxin, neuro­mo­dulation, percutaneous stimulation of the tibial nerve) - and rarely - invasive thera­pies. ]

Lege Artis Medicinae

NOVEMBER 15, 2019

[Hypertension in the elderly ]

BARNA István

[Elevated isolated systolic pressure is the most common and greatest cardiovascular risk factor with age. The prevalence of hypertension increases with age and ex­ceeds 60% over 70 years. Proper treatment of hypertension in the elderly, even in very old age (> 80 years), increases life expectancy and reduces the risk of cardiovascular events. For patients over 65 years of age, the target blood pressure range is between 130-139 / 70-80 mmHg if the patient tolerates the treatment. In elderly patients with poorer conditions, systolic blood pressure may be <150 mmHg. White-coat hypertension is common, nondipper ratio is increased, autonomic nervous system dysregulation is more common, and orthostatic decrease of blood pressure. The renal function is decreased or already impaired, often resulting in poorer therapeutic cooperation due to impaired cognitive function. The blood pressure lowering effect of targeted lifestyle changes may be the same as medication monotherapy, with the main disadvantage of decreasing adherence over time, for which a proper physician-patient relationship is essential. First-line agents for the treatment of elderly hypertension include angiotensin converting enzyme inhibitors (ACE inhibitors), angiotensin receptor blockers (ARBs), long-acting calcium channel blockers, and thiazide, thiazide-like diuretics. Beta-blockers should be used in the treatment of elderly hypertension if they have other indications (coronary heart disease, heart failure, arrhythmias). More than 70% of hypertensive patients should use combination therapy to achieve target blood pressure. Take advantage of fixed dose combination to improve compliance to optimize treatment. ]

Lege Artis Medicinae

NOVEMBER 15, 2019

[Hypertensive emergency conditions in Family practice]

TORZSA Péter

[Family doctors play an important role in the treatment of high blood pressure emergencies. There are two forms of these: hypertensive, non-life-threatening states (urgency) and the hypertensive crisis (emergency) with life-threatening complications. The boundary between these two forms is not sharp, and a non-life-threatening urgency can turn into a hypertensive crisis. Hypertensive emergency is defined as an acute, marked increase of blood pressure with concomitant life-threatening target organ dysfunction. Treatment always requires hospitalization and parenteral administration of antihypertensive agents. In the case of hypertensive urgency, the acute increase of blood pressure is not complicated with organ damage. In these cases treatment can be performed in primary care with oral drugs. ]